Editor’s note: IASP will be celebrating its 50th anniversary in 2024. Even though the anniversary is still a few years away, it already has us thinking about the history of IASP and the evolution of pain research over the past five decades. So we've been talking with senior leaders in the field who have made major contributions to IASP or to pain research and care more generally.
The interview below features one of those leaders, Kenneth Craig, PhD. Dr. Craig is professor emeritus of Psychology at the University of British Columbia in Vancouver, Canada. His research focuses on pain assessment using nonverbal methods in populations with communication limitations, including infants, young children, people with intellectual disabilities, cognitive impairments and dementias; voluntary and automatic control in pain expression; and the importance of psychosocial factors in understanding and controlling pain, described in the social communication model of pain. He is also an honorary member of IASP and has served on the IASP Council (see full bio below).
Here, Craig speaks with Catherine Paré, a PhD candidate in clinical psychology at McGill University, Montreal, Canada, to discuss his journey in the pain research field including his work exploring the influence of social factors on pain, the IASP definition of pain, and much more. Below is an edited transcript of their conversation.
I’d like to start by going back to 1964, which is the year you completed your PhD. Your thesis was titled Partner Competency and Prior Success-Failure Experiences as Determinants of Manding in Dyadic Interactions. How did you end up in pain research from there?
I had the pleasure of working with a brilliant man, Fred Kanfer, my research supervisor at Purdue University, for my PhD. Fred was very interested in social interaction processes during psychotherapy and the concept of manding, which relates to how people seek care in the course of interacting with other people. I then did a research fellowship and internship at the Oregon Health Sciences University with Joe Matarazzo, Chair of Medical Psychology, who was very interested in the timing of interactions during psychotherapy. These people chipped in stone my interests in social processes during clinical interactions.
When I began to work as a research assistant professor at UBC [University of British Columbia], I became interested in how people responded empathetically to others in the course of psychotherapy treatment and in social interactions in general. We developed a lab model for the study of empathy, exposing student volunteers to stress and looking at psychophysiological recordings of observers watching them.
The use of mild artificial pain intrigued us, so we explored electric shock, cold pressor and noxious heat to instigate pain and became hooked on the importance of psychosocial factors as determinants of the experience. I began looking at the social context to see if variations in it impacted how people reacted. We rapidly discovered that the presence of other people, and how those people reacted to pain, had a particularly powerful impact on reactions to pain.
A few years earlier, in the mid-sixties, George Engel came out with his biopsychosocial model in medicine, and Ron Melzack, Pat Wall, and Ken Casey came out with seminal papers on the complexity of the pain experience and the importance of conceptualizing it in terms of the biopsychosocial model. Richard Sternbach and Bill Fordyce also provided inspiration. Still, back then and even now, the vast majority of research was devoted to understanding biological systems and biological interventions in pain. I thought that there was a pretty big niche in talking about the social wing of the biopsychosocial model, and that it was well worthwhile continuing my investigations. It was also the result of the cumulative number of studies coming out of my lab and other people’s labs that showed the very powerful influence of context on how people react when they’re in pain, how they respond to treatment and whether they recover or not.
Overall, as a psychologist, I thought it was important in my career to look at cognitive factors like catastrophizing; emotional factors like anxiety and depression that are so common amongst people with pain; behavioral factors, such as fear-avoidance and the vicious cycles that are associated with behavioral avoidance of activity; and the social factors, including the challenges of work, family, and friends, and also the social stigma and discrimination imposed upon people suffering from chronic pain, which can be truly vicious and disabling in their own right. And that is to say little about the important life history and developmental processes responsible for variations in all these psychosocial determinants of pain.
Could you speak a little bit more about the world of pain research in the sixties and seventies?
It was quite an exciting time because the Canadian Pain Society was founded during that time, following the founding of the International Association for the Study of Pain in 1974. I was delighted to join as a founding ember of IASP; everybody who joined that year would have been a founding member. I’ve been a devotee of IASP since the early seventies and have attended every World Congress.
The core group of people who brought it together, John Bonica and many others, were my inspiration and my heroes, unquestionably. What I saw was the big names in pain research and management worldwide coalescing into a coherent group, and it was just such a wonderful group to join, to belong to and to be able to interact with. I remember going to a meeting and introducing myself to John Bonica, saying “I’m Ken Craig,” and he said that he knew that. That was cool, to have recognition from John Bonica.
How did the formation of IASP impact the world of pain research?
Pain research truly took off and it accelerated the productivity of scientists around the world dramatically. PAIN became the premier journal – an excellent scientific journal with excellent peer review feedback to authors. The journal was receptive to my papers early in the game, even though I don’t think people felt that social factors were truly important. If you could state a scientific case with decent experimental design that demonstrated the power of social factors and social interventions, then people were inclined to support the paper and it got published.
What are your thoughts on IASP’s original definition of pain and its evolution over the course of your career?
I use the IASP definition of pain – I even quote it in my early papers – and I have no difficulty talking about its many admirable features, including an emphasis on subjective experience, and attention to both sensory and emotional experience. However, over the decades, I came to recognize that the definition was too narrow or constrictive and didn’t recognize important factors like cognition and the social environment. For example, the family environment socializes people to think in particular ways about the nature of their experience. As a clinical psychologist, it was very clear that the social environment was critical in understanding how people were suffering and what kinds of interventions were appropriate. The definition of pain recognizes that we learn about the nature of pain as we grow up, but it doesn’t talk about the implications of this on how people experience acute or chronic pain.
I feel that, by acknowledging sensory and emotional features, the definition has worked well for biomedical interventions, in particular pharmacological interventions. But, if we recognize the complexity of the pain experience as comprising thoughts, the social environment and emotions as well as the sensory qualities, we would be ahead of the game. By acknowledging these factors, we would be in a position to leverage treatments that focus on these factors specifically. Dan Carr has argued that maybe we should be reformulating the model as the sociopsychobio model because of the importance of social factors in the treatment of people suffering from persistent pain – I liked that, of course.
You published a paper in the nineties calling for an update to the definition of pain, and you also published a similar paper again in 2016. Do you feel like the changes that you’ve called for are reflected in the 2020 update to the definition of pain?
In the 1990s, Sunny Anand and I recognized that the definition of pain emphasized self-report. We argued forcefully in an editorial in PAIN that it should be revised to recognize that people without verbal communication capabilities were able to communicate their distress through other modalities. The IASP Committee on Taxonomy was very responsive and published an addendum that emphasized the importance of paying attention to nonverbal expression when looking at pain in infants and very young children, populations characterized by undeveloped or impaired brain capacities, and in elderly people suffering from dementia. That was very satisfying.
In the 2016 paper, Amanda Williams and I called for an update of the definition of pain and emphasized adding cognitive and social factors as features of the experience. However, the recently revised IASP definition chose to exclude those characteristics; I think it was a missed opportunity for advancing the field and encouraging innovative thinking and treatment interventions. So I’d like to continue to contribute to a continuing consideration of the definition. More papers are on the way….
How does the new definition impact people who live with pain?
Very powerfully. I think it endorses the status quo, and so it won’t have the capacity to encourage novel interventions that more broadly embrace the biopsychosocial model of pain. Over the decades there hasn’t been an expansion of multidisciplinary pain clinics that should have taken place. I also think there’s more unimodal treatment in primary medical care, so I’d like to see more multidisciplinary care established. A broader definition of pain would encourage that.
Can you talk about some of your research over the years on the social context of pain and how to assess it?
Since the sixties and the seventies, people have encouraged and embraced thinking about social factors; at that time, the Canadian funding agencies supported this research, including my lab’s work. But, in the original studies looking at social models for people experiencing pain, I found myself unhappy with self-report of the pain as an index of the experience and wondered if there were better measures of painful experience.
My lab embarked on research programs in which we used peripheral psychophysiological measures – electrodermal activity, heart rate, muscle tension and respiration rate – to see whether the social context would influence these very fundamental measures of sensory experience. Indeed, they did, and it was quite persuasive to me.
We then became interested in nonverbal expression; it was Ken Prkachin, one of the first PhD students in my lab, who began this focus using an objective, anatomically based index of facial activity. Faces are accessible information and very important in terms of interpersonal dynamics. Facial expression also doesn’t seem to be as amenable to censoring and editing as is what we say at any given moment.
So we began to use movie cameras and record the facial reactions of people suffering from pain, in lab research and then in clinical settings with people suffering from chronic pain and doing painful movements. We found that nonverbal expression – facial activity in particular – was both expressive of pain and also influenced by the social context, which affirmed these lines of research.
Considering the limitations of self-report, what role do you think it should play?
Self-report remains important, and you cannot interact with other people without using speech and language as the primary medium. When I do a clinical interview, I ask about what’s happening to the person in great detail, but I am still using self-report. The continuing problem is the use of unidimensional pain scales that just focus on sensory intensity. They’re exceedingly narrow and fail to capture the complexity of the experience – all those thoughts, feelings and emotions. We’ve known since the sixties and seventies that pain has sensory-discriminative, emotional-motivational, and cognitive appraisal aspects. Multidimensional scales such as the McGill Pain Questionnaire are prized because they capture the complexity of pain. The key is appreciating the complexity of the determinants of human expression. Social interventions, like psychotherapy for example, can inhibit or facilitate the experience and expression of pain in different ways.
My interest in nonverbal expression expanded to look at populations who have difficulty verbally articulating their distress. My research at this stage of the game attempted to address the complexity of nonverbal pain expression using multidimensional parameters. With one of my graduate students, Ruth Grunau, now an investigator at the BC Children’s Hospital, we examined pain expression in neonates using a facial expression coding system. We’ve also explored facial expression of pain in school-age children, and in other nonverbal populations. At the elderly end of the life span, work with Thomas Hadjistavropoulos, now a professor at the University of Regina, led to exploration of the nature of pain in elderly persons with dementia using nonverbal measures.
Even though there’s been a huge emphasis on nonverbal expression in these populations, that work doesn’t seem to truly acknowledge how important nonverbal expression is in cognitively and socially competent adults. If we are successful in addressing the multidimensionality of nonverbal pain expression, then biomedical interventions could be focused on sensory and affective features of pain, while the emotional and cognitive appraisal factors would be more amenable to intervention through the use of cognitive behavioral therapy.
You’ve published a few papers on pain in marginalized communities. I can’t help but take those papers in our current global context, where countries all over the world are emphasizing social justice, in large part stemming from the Black Lives Matter movement that originated in the United States. Do these events fit into how we conduct pain research now?
The current interest in inclusivity, equity, and justice in the delivery of care is enhancing consciousness about these phenomena. When COVID started so dramatically to impact our lives, I thought that we should be focusing more on the populations who are particularly vulnerable, which tend to be marginalized people. There was a reluctance amongst public health officials at that time to identify demographic characteristics of the people who were suffering most. We now know that it’s disadvantaged people who are particularly vulnerable to the disease.
There are parallels in terms of pain research and pain management. People suffering from chronic pain are often marginalized, but it’s the intersectionality that is so important. If you’ve also been marginalized by virtue of skin color, ethnic background, socioeconomic status, religion, or for any other reason, the likelihood that you will have access to good care for persistent pain, and that people will be truly sympathetic, caring, and helpful diminishes dramatically. It behooves clinics to begin to collect population data that relate to these factors and to look at the kinds of care that these people are receiving.
It’s the access to care that’s the primary issue for me. We developed this research interest in collaboration with Pain BC, their excellent executive director, Maria Hudspith, and a number of people in nursing at UBC with strong interest in equity and the delivery of care, and with people in social work at the University of Victoria. We’ve been working with people in Indigenous communities, the LGBTQ population, refugees, and immigrants, and we’ve done focus groups and workshops to try to get at an understanding of the challenges that they have encountered in pain care. They talk about discrimination in the healthcare system, in their informal friendship patterns, and sometimes even in members of their family who fail to have sympathy for their persistent pain.
Coming back to IASP, could you say a little bit more about how it has influenced the field of pain research in the last 50 or so years?
It’s had a huge influence. IASP is a powerful international organization and that is because of its membership. I was privileged a decade or so ago to sit on the IASP Council. I got a good look at the inner workings of IASP and that only enhanced my respect for the people who commit themselves on a voluntary basis to professional leadership in the organization.
I’m delighted by the extent to which the professional and scientific focus on pain has expanded over the decades. One of the great things IASP has done has been to encourage the development of pain societies and better care for people suffering from pain around the globe, recognizing that everything depends upon what’s happening at the grassroots. The Canadian Pain Society, which is the Canadian chapter of IASP, is a wonderful example of a very successful and effective organization at the national level.
The IASP special interest groups [SIGs] are also very important. One of the earliest and, I think, most effective SIGs has been the Pain in Childhood group. Wonderful collaborations and lots of wonderful collegiality with people around the world have been the result of that particular SIG. A more recent SIG is the Social Aspects of Pain group, which is a good example of how IASP is responsive to newly identified problems. Another SIG that I belong to and believe fervently in is the SIG on Pain Related to Torture, Organized Violence and War, because it accelerates our attention to the potential for pain arising from violence towards others. It also makes us think about the plight of people around the world who are not as privileged as I definitely am.
You once received the mentorship award from the Canadian Pain Society. What was that like?
It was very pleasing to have that recognition. But I’ve been blessed by absolutely superb students. I mentioned Ken and Ruth, and I should also mention Rebecca Pillai Riddell, Heather Hadjistavropoulos and Christine Chambers, and a whole bunch of other people. Collaborating with students has been absolutely wonderful, and I encourage people to be very positive about that.
What do you hope to see for the future of pain research?
Research on pain in vulnerable populations has been truly inadequate at this stage of the game. Another IASP SIG that I enthusiastically support is the Pain and Intellectual Developmental Disabilities SIG. When I look at the paucity of research in these populations, I begin to recognize how privileged some people are in terms of the consideration they receive in research and in pain management. Vulnerable populations are neglected and need to be brought into the mainstream much more enthusiastically.
Catherine Paré is a PhD candidate in clinical psychology at McGill University, Montreal, Canada.
About Kenneth Craig
Kenneth D. Craig, OC, PhD, FCAHS, LLD (Hon.) is professor emeritus of Psychology at the University of British Columbia in Vancouver, BC, Canada. Following studies at Concordia University, UBC, Purdue University and the Oregon Health Sciences University, his academic career has been at UBC. His research focuses upon pain assessment using nonverbal methods in populations with communication limitations, including infants, young children, people with intellectual disabilities, cognitive impairments and dementias; voluntary and automatic control in pain expression; and the importance of psychosocial factors in understanding and controlling pain, described in the social communication model of pain. He has been Editor-in-Chief of Pain Research & Management and the Canadian Journal of Behavioural Science and has served as president of the Canadian Pain Society and the Canadian Psychological Association and on the Council of the International Association for the Study of Pain. Awards include appointment as an IASP honorary member, the Canada Council I.W. Killam Research Fellowship, appointment as a Canadian Institutes of Health Research Senior Investigator, the Canadian Pain Society Distinguished Career Award, the American Pain Society Jeffrey Lawson Award for Advocacy in Children’s Pain Relief, an honorary LL.D. from Dalhousie University, and investiture as an Officer of the Order of Canada.